Introduction

Doppler-guided artery ligation with Mucopexy, or HAL-RAR, is a minimally invasive surgical technique that allows for better postoperative comfort. An anoscope linked with a light source and a doppler probe allows the proctologist to locate the submucosal branches of the superior rectal artery and to ligate them via a transfixing parietal approach. Mucosal pexis is performed afterward : the mucosa of the prolapsed hemorrhoidal pedicles is vertically sutured, consequently leading to a plication of the prolapsed muco-hemorrhoidal tissue and its reposition inside the canal anal. Nevertheless, long-term recurrence rate of internal hemorrhoidal disease after this procedure has been poorly studied.

Aims & Methods

The aim of our study is to evaluate the long-term recurrence rate of hemorrhoidal disease post Doppler-guided artery ligation (HAL-RAR) with Mucopexy in our center.
An ambispective observational and analytical study was conducted over a 5-year period, from January 2017 to January 2022. Surgical indications included grade II and III internal hemorrhoids that resisted to medical treatment and small localized non-circumferential grade IV hemorrhoids. Patients with external hemorrhoids, bulky grade IV hemorrhoids or pelvic floor disorders were excluded.
All data were analyzed using Jamovi version 2.0.0.0 software. Patient characteristics were described as number and percentage for qualitative items and median (interquartile range [IQR]) or mean (± standard deviation) for quantitative ones. A p value of ≤0.05 was deemed to be significant.
Our primary objective was to evaluate the rate of recurrence more than 24 months after surgery. The secondary objectives were to determine the clinical features of relapsing patients.

Results

114 patients were included in this study. The mean age was 46.5 ± 9.6 years. The sex ratio was 6 (16f, 98H). Preoperatively, 69% (n=79) of the patients reported proctalgia, 53% (n=60) post-defecation rectal pain and 58% (n=66) prolapse. We staged the internal hemorrhoidal disease according to Goligher's classification, identifying 32 with grade II hemorrhoids, 61 with grade III hemorrhoids and 21 grade IV hemorrhoids.
At the end of a median follow-up of 4 years (7-2), 9 patients (7.9%) presented a recurrence, made in 6 cases of a muco-hemorrhoidal prolapse and in 3 cases of post-defecation rectal bleeding. None of our patients presented with anal stenosis or incontinence during the follow-up period. In our study, there was no statistically significant relationship between the recurrence and the preoperative clinical symptomatology (p=0.21) nor with grade of hemorrhoids (p=0.17). Overall, 94% of the patients included were satisfied with this technique. 4 of the patients who relapsed benefited from Milligan-Morgan hemorrhoidectomy. However, they claimed that they were more satisfied following the HAL-RAR procedure.

Conclusion

Transanal doppler-guided hemorrhoidal artery ligation with mucopexy (HAL-RAR) is easy to perform and is a safe minimally-invasive technique. It can be considered an effective long-term treatment for internal hemorrhoidal disease.

Introduction

Doppler-guided artery ligation with Mucopexy, or HAL-RAR, is a minimally invasive surgical technique that allows for better postoperative comfort. An anoscope linked with a light source and a doppler probe allows the proctologist to locate the submucosal branches of the superior rectal artery and to ligate them via a transfixing parietal approach. Mucosal pexis is performed afterward : the mucosa of the prolapsed hemorrhoidal pedicles is vertically sutured, consequently leading to a plication of the prolapsed muco-hemorrhoidal tissue and its reposition inside the canal anal. Nevertheless, long-term recurrence rate of internal hemorrhoidal disease after this procedure has been poorly studied. The aim of our study is to evaluate the long-term recurrence rate of hemorrhoidal disease post Doppler-guided artery ligation (HAL-RAR) with Mucopexy in our center

Aims & Methods

The aim of our study is to evaluate the long-term recurrence rate of hemorrhoidal disease post Doppler-guided artery ligation (HAL-RAR) with Mucopexy in our center.
Materials and Methods:
An ambispective observational and analytical study was conducted over a 5-year period, from January 2019 to January 2024. Surgical indications included grade II and III internal hemorrhoids that resisted to medical treatment and small localized non-circumferential grade IV hemorrhoids. Patients with external hemorrhoids, bulky grade IV hemorrhoids or pelvic floor disorders were excluded. All data were analyzed using Jamovi version 2.0.0.0 software. Patient characteristics were described as number and percentage for qualitative items and median (interquartile range [IQR]) or mean (± standard deviation) for quantitative ones. A p value of ≤0.05 was deemed to be significant. Our primary objective was to evaluate the rate of recurrence more than 24 months after surgery. The secondary objectives were to determine the clinical features of relapsing patients.

Results

114 patients were included in this study. The mean age was 46.5 ± 9.6 years. The sex ratio was 6 (16f, 98H). Preoperatively, 69% (n=79) of the patients reported proctalgia, 53% (n=60) post-defecation rectal pain and 58% (n=66) prolapse. We staged the internal hemorrhoidal disease according to the Goligher classification, identifying 32 with grade II hemorrhoids, 61 with grade III hemorrhoids and 21 grade IV hemorrhoids. At the end of a median follow-up of 4 years (7-2), 9 patients (7.9%) presented a recurrence, made in 6 cases of a muco-hemorrhoidal prolapse and in 3 cases of post-defecation rectal bleeding. None of our patients presented with anal stenosis or incontinence during the follow-up period. In our study, there was no statistically significant relationship between the recurrence and the preoperative clinical symptomatology (p=0.21) nor with grade of hemorrhoids (p=0.17). Overall, 94% of the patients included were satisfied with this technique. 4 of the patients who relapsed benefited from Milligan-Morgan hemorrhoidectomy. However, they claimed that they were more satisfied following the HAL-RAR procedure

Conclusion

transanal doppler-guided hemorrhoidal artery ligation with mucopexy (HAL-RAR) is a safe, quick, easy to perform technique and can be considered an effective long-term treatment for internal hemorrhoidal disease.

Clinical Case Summary

Colorectal lymphomas are a rare cause of colonic neoplasia (0.2-0.6% malignant neoplasms of large bowel). Approximately 10% are primary colorectal lymphomas, while the rest correspond to colonic extension of systemic lymphoproliferative diseases.
We present the case of a 66-year-old woman with a history of rectum and pancreas adenocarcinoma (both in remission). During a follow-up CT, a thickening of the cecal pole was identified, with no adenopathy or other relevant findings (Photo1). The patient had no abdominal pain or B symptoms (night sweats, weight loss or fever).
The diagnosis was completed with a PET-CT that showed pathological uptake in the cecum (Photo2), so a colonoscopy was performed, which revealed a large polypoid lesion (30 mm) at the ileocecal level, with nodular areas with small ulcerations and no clear loss of the glandular pattern (Photo 3), from which multiple biopsies were taken.
Biopsies showed lymphoid proliferation with a ‘starry sky’ pattern, mitosis and apoptosis, and positive immunohistochemistry for CD45, CD20, CD10, BCL6, BCL2 and C-MYC, together with a high proliferation index (Ki-67 > 95%), all compatible with high-grade B-lymphoproliferative syndrome with Burkitt morphology (Photo 4).
Burkitt's lymphoma is a rare B-cell lymphoma (15% of GI lymphomas), associated with chromosomal translocation (8:14, 8:22 and 2:8) and overexpression of c-myc oncogene.
There are three clinical variants: endemic (common in Africa and associated with EBV and malaria), HIV-associated and sporadic (20%).
It is common in children and its most frequent symptoms are abdominal pain and weight loss, so diagnosis is often delayed. Although the yield of endoscopic biopsies is low (<20%), it is a key tool in its diagnosis, along with targeted biopsy of abdominal adenopathies.
Despite its aggressiveness, treatment with targeted chemotherapy achieves rates of more than 90%, and early diagnosis is essential to avoid complications and ensure adequate medical treatment.

References

- Photo 1: Thickening of the cecal pole seen in CT-Scan.
- Photo 2: Pathological uptake in the caecal area as seen on PET-CT Scan.
- Photo 3: Polypoid lesion in ileocecal area at colonoscopy
- Photo 4: Pathological anatomy of endoscopic biopsies: starry sky imaging and immunohistochemistry of Bcl-2 and C-myc

Introduction

Patients with primary biliary cholangitis (PBC) are at an increased risk of developing cirrhosis and eventually experiencing hepatic decompensation. While there is increasing evidence for more prevalent aetiologies of cirrhosis that a successful removal/suppression of the underlying aetiological factor can induce significant improvements in liver function and even enable hepatic recompensation, similar insights in PBC are scarce.

Aims & Methods

In this study, we aimed to explore clinical implications of hepatic recompensation according to the novel Baveno VII criteria in PBC, while considering a biochemical response to ursodeoxycholic acid (UDCA) according to Paris-II criteria as surrogate marker of a successful aetiological treatment. Specifically, we included cirrhotic PBC patients at the time of first hepatic decompensation (ascites, hepatic encephalopathy [HE], variceal bleeding) and analysed their subsequent clinical disease course. In accordance with Baveno VII criteria, we defined hepatic recompensation as (i) resolution of ascites and HE despite discontinuation of diuretics and HE treatment, (ii) absence of variceal bleeding and (iii) sustained improvements in biochemical liver function.

Results

This study enrolled 42 PBC patients with decompensated cirrhosis (age: 63.5 [IQR:51.9-69.2] years; 88.1% female) who were followed-up for a median of 41.9 (IQR:11.0-70.9) months after decompensation. The cause of index decompensation was ascites in 54.8%, variceal bleeding in 35.7% and HE in 9.5% of cases. At time of decompensation, the median MELD-Na was 14 (IQR:11-15). Overall, 33 patients were treated with UDCA for at least 1 year (median dose: 12.5 [IQR:10.7-15.0] mg/kg) and 36% of those (12/33) achieved the Paris-II response criteria.
Over the course of the study, 7 patients (16.7%) achieved recompensation. In a competing risk model, baseline parameters linked to a higher probability of recompensation included a lower MELD-Na (SHR: 0.90; 0.047), a lower Child-Pugh score (SHR: 0.59; p=0.019), lower bilirubin (SHR: 0.44; p=0.005), lower alkaline phosphatase (SHR: 0.96; p=0.001) and variceal bleeding as index decompensation (SHR: 4.37; p=0.069). Interestingly, while 5/12 (42%) UDCA responders recompensated and a response at 1 year was linked to a higher probability of recompensation (SHR: 5.08; p=0.041), 2/21 (10%) patients without UDCA response still eventually achieved recompensation.
Regarding prognostic implications, recompensation was linked to a numerically improved transplant-free survival in a time-dependent Cox regression model (HR: 0.46; p=0.335). Specifically, 3 recompensated patients survived without any further complications or the need for liver transplantation over a follow-up time of 35, 40 and 294 months after recompensation. Nevertheless, the remaining 4 recompensated patients presented with liver-related complications after developing hepatic malignancies and/or portal vein thrombosis (PVT) and two eventually died (18 and 29 months after recompensation). In contrast, of the patients who remained decompensated, 10 underwent liver transplantation (29%) and 17 died (49%).

Conclusion

Patients with decompensated cirrhosis due to PBC may achieve hepatic recompensation under UDCA therapy, particularly if the degree of liver dysfunction at index decompensation is less pronounced. Nonetheless, recompensated patients should be monitored carefully for the development of hepatic malignancy and PVT, as liver transplantation may still be required.

Disclosure

Albert Friedrich Stättermayer: Speaker and/or consultant and/or advisory board member for Boehringer Ingelheim, Gilead, and MSD. Benedikt Simbrunner: Travel support from AbbVie and Gilead. Mattias Mandorfer: Speaker and/or consultant and/or advisory board member for AbbVie, Collective Acumen, Gilead, and W. L. Gore & Associates; Travel support from AbbVie and Gilead. Michael Trauner: Grant support from Albireo, Alnylam, Cymabay, Falk, Gilead, Intercept, MSD, Takeda and UltraGenyx; Honoraria for consulting from Albireo, Boehringer Ingelheim, BiomX, Falk, Genfit, Gilead, Intercept, MSD, Novartis, Phenex, Pliant, Regulus and Shire; Speaker fees from Bristol-Myers Squibb, Falk, Gilead, Intercept and MSD; Travel support from AbbVie, Falk, Gilead and Intercept. Thomas Reiberger: Grant support from Abbvie, Boehringer-Ingelheim, Gilead, Gore, Intercept, MSD, Myr Pharmaceuticals, Philips Healthcare, Pliant, and Siemens; Speaking honoraria from Abbvie, Gilead, Gore, Intercept, Roche, MSD; Consulting/advisory board fee from Abbvie, Bayer, Boehringer-Ingelheim, Gilead, Intercept, MSD, Siemens; Travel support from Abbvie, Boehringer-Ingelheim, Gilead and Roche.

Introduction

Patients with metabolic-dysfunction associated steatohepatitis (NAFLD activity score ≥4) and significant fibrosis (≥F2) (fibrotic MASH) are at increased risk for disease progression and development of cirrhosis. Following the recent approval of the first agent for the management of noncirrhotic MASH, timely identification of these patients is of major importance. Fibroscan-aspartate aminotransferase (FAST^TM) score enables the noninvasive diagnosis of fibrotic MASH, and has been assessed in several studies.

Aims & Methods

To assess the overall performance of FAST^TM score for diagnosing fibrotic MASH. We searched Medline, Cochrane library, Web of science and Scopus up to January 2024. We included diagnostic accuracy studies assessing the performance of FAST^TM score for ruling out (FAST^TM score ≤0.35) and ruling in (FAST^TMscore ≥0.67) fibrotic MASH using liver biopsy as the reference standard. We calculated pooled diagnostic accuracy estimates using bivariate random-effects models, and assessed risk of bias using the Quality Assessment of Diagnostic Accuracy Studies 2 tool.

Results

We included 16 studies with 8838 participants. Most studies (87.5%) were at high or unclear risk of bias due to concerns regarding patient selection, interpretation of FAST score without knowledge of biopsy results, and length of biopsy specimens for fibrotic MASH diagnosis. Across all participants, 54.8% were females and 31% had type 2 diabetes. Mean age and body mass index (BMI) were 52.4 years and 32.4 kg/m². Mean aspartate aminotransferase and alanine aminotransferase were 45.0 IU and 57.6 IU, respectively. The prevalence of fibrotic MASH across studies was 32.9% ranging from 14% to 55%. Using the rule out cut off (≤0.35), FAST^TM yielded a pooled sensitivity of 0.88 (95 % CI; 0.83, 0.91), specificity 0.52 (0.45, 0.60), positive likelihood ratio (LRp) 1.8 (1.6, 2.1) and negative likelihood ratio (LRn) 0.23 (0.18, 0.30). By applying the rule in cut off (≥0.67), pooled sensitivity, specificity, LRp, and LRn were 0.45 (0.39, 0.52), 0.87 (0.82, 0.90), 3.4 (2.8, 4.1) and 0.63 (0.58, 0.69) respectively. Assuming a pre-test probability (prevalence) of 30% for fibrotic MASH, a FAST^TM score ≥0.67 resulted in a positive predictive value of 60%, while with a FAST^TM score ≤0.35 the negative predictive value was 91%.

Conclusion

FAST^MT score has acceptable accuracy for the diagnosis of fibrotic MASH. Proposed thresholds of ≤0.35 and ≥0.67 might be useful for ruling out/in fibrotic MASH respectively.

Introduction

Recently, a novel self-assembling peptide hemostatic gel has become available in Japan. However, the safety and efficacy of this novel self-assembling peptide hemostatic gel remain unclear for bleeding after EST.

Aims & Methods

The aim of this study was to evaluate the safety and efficacy of a novel self-assembling peptide hemostatic gel for bleeding after EST, and compared to conventional endoscopic hemostasis technique.
This retrospective study was carried out between January 2019 and October 2022. Patients who developed bleeding associated with EST were enrolled. The patients were divided into two groups based on the hemostasis techniqueused: a conventional hemostasis technique (Group A) or a novel self-assembling peptide hemostatic gel hemostasis technique (Group B).

Results

A total of 62 patients (Group A, n=36; Group B, n=26)were included. Endoscopic hemostasis was initially obtained in 72.2% (26/32) of patients in Group A and in 88.4% (23/26) of patients in Group B, with no significant difference (P=0.1211). However, the procedure time was significantly shorter in Group B (mean, 9.38 min) compared with Group A (mean, 15.4 min) (P=0.0103).There were no significant differences in the severity of bleeding between the two groups (P=0.4468). post-EST bleeding was observed in 6 patients (Group A, n=4; Group B, n=2). although there was no significant difference (P=0.6532), adverse events were more frequently observed in Group A (n=12) than in Group B (n=1).

Conclusion

PuraStat application for EST bleeding might be safe and effective, and comparable to the conventional endoscopichemostasis technique, although further prospectiverandomized trial is needed.